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Based on interview and record review, the Critical Access Hospital (CAH) failed to assure the required "An Important Message from Medicare" information form (a document which informs patients of their rights to receive Medicare covered services and is required to be provided to all qualified Medicare patients) was provided to 6 of 11 Medicare patient (P3, P5, P13, P14, P17, P21) beneficiaries reviewed in the sample.

Findings include:

P3's Admission Summary Sheet indicated P3 was admitted to the CAH on 4/14/14. P3's clinical record lacked evidence of having been given the "An Important Message from Medicare" information for this admission.

P13's Admission Summary Sheet indicated P13 was admitted to the CAH on 1/11/14. P13's clinical record lacked evidence of having been given the "An Important Message from Medicare" information for this admission.

P17's Admission Summary Sheet indicated P17 was admitted to the CAH on 4/24/14. P17's clinical record lacked evidence of having been given the "An Important Message from Medicare" information for this admission.



15508

P5's Admission Summary Sheet indicated P5 was admitted to the CAH on 7/11/13. P5's clinical record lacked evidence of having been given the "An Important Message from Medicare" information for this admission.


P14's Admission Summary Sheet indicated P14 was admitted to the CAH on 7/22/13. P14's clinical record lacked evidence of having been given the "An Important Message from Medicare" information for this admission.


P21's Admission Summary Sheet indicated P21 was admitted to the CAH on 5/5/13. P21's clinical record lacked evidence of having been given the "An Important Message from Medicare" information for this admission.


On 4/17/14, at 3:20 p.m. the CAH's chief financial officer (CFO) confirmed the above patients had not received the medicare information and stated the "An important Message from Medicare" form was to be given to all Medicare patients as required.

Based on interview and record review, the Critical Access Hospital (CAH) failed to ensure patients right to privacy was respected during triage in the emergency room for all patients that utilized the CAH's emergency room services.


The findings include:


Minnesota statute 144.651 HEALTH CARE BILL OF RIGHTS identified the following: "Treatment Privacy- Patients shall have the right to respectfulness and privacy as it relates to their medical and personal care program. Case discussion, consultation, examination and treatment are confidential and shall be conducted discreetly. Privacy shall be respected during toileting, bathing and other activities of personal hygiene, except as needed for patient safety or assistance."

On 4/15/14, at 11:20 a.m. a tour of the emergency room was conducted. The emergency room was observed to have five bays separated by a curtain or door. A private area to triage emergency room patients was not observed. At this time, registered nurse (RN)-D stated the emergency room patients were triaged in the middle of the emergency room and then placed in the most appropriate room depending on the chief complaint of the patient. RN-D confirmed that by triaging patients in the middle of the emergency room, current emergency room patients and their visitors could see and hear other patients chief complaints and medical history.


On 4/16/14, at 3:48 p.m. RN-E verified emergency room patients were triaged in the middle of the emergency room and then placed in the most appropriate room there after depending on the chief complaint of the patient. RN-E confirmed patient triage was not completed in a private area.


On 4/18/14, at 12:05 p.m. The CAH's Administrator confirmed the CAH's emergency room department did not have a private area to triage patients.


A policy related to patient privacy and triaging patients in the emergency room was requested but not provided.

Based on interview and document review, the Critical Access Hospital (CAH) failed to assure the medical staff and/or governing body approved credentialing for appointment or reappointment for 2 of 11 providers (MD-A, MD-B) currently working in the CAH. In addition, the CAH failed to provide evidence of the appointment of the chief executive officer (CEO).

Findings include:

On 4/16/14, at 9:50 a.m. the chief executive officer (CEO) confirmed the facility was unable to provide documentation of medical doctor (MD)-A's appointment by the medical staff or governing body and the reappointment by the governing body for MD-B.

On 4/16/14, at 3:00 p.m. the CEO confirmed MD-A had started employment with Mahnomen Health Center (MHC) on 5/31/13, and was currently working at the facility. The CEO verified the initial appointment for MD-A was for 2/20/13, through 2/20/15. The CEO also confirmed MD-B was currently working at MHC and had been up for reappointment for the time period of 1/23/14, through 1/23/16.

The CAH's Credentialing Plan dated 2013, indicated after approval of the medical staff, the inquiry for privileges would be brought to the MHC monthly board meetings for their approval. Only those providers whose credentials had been verified, affirmatively reviewed and approved would be able to provide care and services to MHC patients.

The facility's Medical Staff Bylaws adopted by the governing board dated 3/27/14, verified the Credentialing Plan noted above would be followed for initial appointment and reappointments.

On 4/16/14, at 4:25 p.m. the chief financial officer (CFO) confirmed the CAH was unable to provide evidence from the governing board minutes which had identified the approval of the appointment for the current CEO. The CFO verified the current CEO had started her employment in June 2002.

Based on interview and document review, the Critical Access Hospital (CAH) failed to assure medical doctors (MD) reviewed and signed the medical records for 5 of 9 (P4, P5, P6, P13, P17) inpatients cared for by mid-level providers as directed by the CAH's policy.

Findings include:

P4's Admission Summary Sheet indicated P4 was admitted to the CAH on 10/6/13, by certified nurse practitioner (CNP)-G. P4's clinical record lacked documentation which indicated the MD was notified of P4's admission and also lacked acknowledgment that the MD had reviewed and approved with the care and management of P4 by CNP-G.

P17's Admission Summary Sheet indicated P17 was admitted to the CAH 4/24/13, and discharged on 4/30/13. CNP-G was P17's admitting provider. The Mahnomen Health Center Notification and Certification form indicated CNP-G had notified medical doctor (MD)-C of P17's admission on 4/24/13, however on 5/31/13, (31 days post discharge), MD-C signed that s/he had reviewed P17's clinical record and agreed with P17's plan of care and management.

On 4/15/14, at 3:00 p.m. the chief executive officer (CEO) verified the CAH's policy indicated the providers were to utilize the Notification and Certification form which documented the mid-level's notification with the MD when a mid-level provider admitted a patient to the CAH and the medical doctor documented that s/he was certifying they had reviewed the clinical record and agreed with the plan of care and management of the patient.

On 4/18/14, at 9:30 a.m. the CEO confirmed the CAH's expectation and policy was that the medical doctors were to be notified of a patient's admission by a CNP and the medical doctor should review and sign off on the record prior to discharge. However, the CEO stated the providers had seven days post discharge to complete their dictation. The CEO confirmed a review of the clinical record by the medical doctor 30 days post discharge would not meet the facility's expectations.

On 4/18/14, at 3:30 p.m. the medical records manager verified P4's Notification & Certification form which acknowledged the medical doctor's awareness of admission and overall agreement with the plan and management of P4 had not been completed.

The MAHNOMEN HEALTH CENTER Medical Records Policy and Procedure dated 8/10/2010, indicated all medical record charts of patients seen by mid-level providers would undergo a review of the chart by the supervising MD or medical director. All charts would be signed by the Medical Director using the Notification and Certification form on the date they were reviewed.




15508

P13's Admission Summary Sheet indicated P13 was admitted to the CAH on 5/5/13, by a CNP. P13's clinical record lacked documentation that the MD had reviewed and approved with the care and management of P13 by the CNP.


P6's Admission Summary Sheet indicated P6 was admitted to the CAH on 8/12/13, by a CNP. P6's clinical record lacked documentation that the MD had reviewed and approved with the care and management of P6 by the CNP.


P5's Admission Summary Sheet indicated P5 was admitted to the CAH on 7/11/13, by a CNP. P5's clinical record indicated on 9/4/13, a MD had reviewed P5's clinical record and agreed with P5's plan of care and management (54 days later).






18617

On 4/17/14, at 2:30 p.m. the medical records specialist was asked to provide a listing or evidence that physicians were reviewing emergency room records for patients that had care provided by mid-level practitioners. The medical records specialist stated that she did not have a list of medical records that had been reviewed for appropriateness of treatment by physicians.

The CAH's Medical Staff Chart Review policy dated 9/2013, revealed 25% of emergency room (ER) patient records should be forwarded by the mid-levels to a medical doctor for cosignatory.


On 4/18/14, at 9:30 p.m. chief executive officer (CEO) confirmed mid-level providers (certified nurse practitioners and physician assistants) should have sent a portion of their patient's clinical records to their assigned medical doctor (MD) for review of the care and management of their patients. The CEO stated this process was not being monitored to assure completion completed according to the CAH's policy. The CEO was unable to provide a list of charts each medical doctor had reviewed or evidence demonstrating follow up was completed when a concern was identified.

On 4/18/14, at 10:30 p.m. the CEO verified there was no evidence of documentation with regards to chart review discussions between the MD and mid-level's as those conversations were done informally.

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to assure the security of 2 of 3 crash carts which were located in bay one of the emergency department and the cardiac rehabilitation department.

The findings include:

On 4/16/14, at 11:55 a.m. the adult crash cart in the emergency department (ED) was observed stationed in the corner of bay one out of the direct sight of staff. At this time the entrance to the ED was observed unlocked as nursing staff were tending to a patient/family in one of the other ED other bays. At this time the pharmacy director confirmed this crash cart was unsecured, stationed out of the direct sight of staff.

On 4/16/14, at 12:10 p.m. the crash cart designated for the cardiac rehabilitation (CR) department was observed stationed in the hallway outside of the CR department. The hallway was observed to have direct access to the outside through an exit door at the end of the hallway. Registered nurse (RN)-B confirmed s/he moved the crash cart out of the CR room and into the hallway during the day when the CR room was being utilized (which was 7:00 a.m. until 3:30 p.m. Monday through Friday). The pharmacy director and RN-B verified when the CR crash cart was stationed in the hallway, was unattended and out of the direct sight of CAH staff. RN-B and the pharmacy director confirmed the hallway outside of CR was used by visitors, patients and staff. During this interview, a staff member was observed to leave out of the exit door at the end of the hallway.

The adult crash cart in the ED and CR department were both observed to have intact numbered breakaway locks and both were out of direct sight of the nursing stations and/or facility staff.

The pharmacy director provided an inventory list of the adult ED and CR crash carts [not an inclusive list]. Both carts contained the following:
? Atropine (treats slow heart rate)
? Lidocaine (treats emergency irregular heart rate)
? Epinephrine (treats cardiac arrest)
? Naloxone (reversal agent for narcotics and treats shock)
? Procainamide (treat life threatening irregular heart rate)
? Amiodarone (treats life threatening heart rate)
? Adenosine (treats irregular heart rate)
? Nitroglycerine (treats chest pain)
? Metoprolol tartrate (treats high blood pressure)

The CAH's MEDICATION STORAGE AREAS policy dated 3/14, indicated all storage areas would be maintained in accordance with state and federal law and professional standards of practice. The policy also indicated medications in crash carts would be secured by either a keyed lock or tear-away seal.

Based on interview and document review, the Critical Access Hospital (CAH) failed to utilize a current therapeutic dietary manual. This had the potential to affect all patients served by the CAH. The CAH's average daily census was 2.3 patients.


Findings include:


The CAH was currently utilizing the "Manual of Clinical Nutrition 2000" which was approved for use by the Director of Nursing, Administrator and Medical Director in February, 2014.


During a telephone interview with the CAH's Register Dietitian (RD) on 4/17/2014, at 10:50 a.m. she confirmed this was the reference manual currently being used by the CAH for patient dietary needs. The RD acknowledged there was some discussion with administration regarding the use of a more current version of a nutritional manual, however, stated it had not been implemented at this time.


On 4/15/14, at 3:45 p.m. the dietary managers stated it was his opinion the current CAH manual was outdated and should no longer be used as a reference for patient nutritional needs.

Based on interview and document review, the Critical Access Hospital (CAH) failed to maintain the Computerized Tomography (CT) equipment as recommended by the Physicist. This has the potential to affect all persons who had physician's order for a CT scan.


Findings include:


In reviewing the physicist report "CT Phantom Site Scanning Data Form" dated 10/9/13, it was noted, under Section 13, the display devices did not pass inspection. The report documented "the monitor is showing burn-in and needs to be replaced."


In an interview with the Department Manager of the radiology, on 4/17/14, at 4:15 p.m. she stated the physicist had been at the CAH in her absence and she had missed seeing the report regarding the need to repair the CT monitor and confirmed due to this miscommunication the physicist recommendation to repair the monitor not been implemented. In addition, she stated she had made arrangements for the repair to be made within the next week.

Based on interview and document review, the Critical Access Hospital (CAH) failed to assure a comprehensive list of all services furnished under agreements or arrangements had been maintained. This had the potential to affect all patients receiving services at the CAH.

Findings include:

The CAH's alphabetized, undated "Contract Index" list provided by the facility had 28 agreements/contracted services crossed out and 49 agreements/contracted services whited out. The list index provided the name of the agreement/contract, however lacked documentation of the scope of the service provided and the contracted services responsibilities.

On 4/15/14, at 1:20 p.m. the chief executive officer (CEO) confirmed the list of agreements and/or contracted services for the facility did not include a description of the services provided or the delineation of the responsibilities of the contracted and/or agreement services. The CEO confirmed the list of contracted services provided was an old list and needed to be updated.

Based on interview and document review, the Critical Access Hospital (CAH) failed to obtain the required consent for treatment for 4 of 20 inpatient (P5, P6, P9, P20) records reviewed. This had the potential to affect all patients serviced by the CAH. The average in house census was 2.3 admissions per day. In addition, the CAH failed to maintain complete medical records to include description of patient progress, response to interventions and disposition at the time of discharge for 1 of 10 emergency room records reviewed.



Findings include:


Patient 5 (P5) was admitted to the CAH on 7/11/13, per P5's Admission Summary Sheet. P5's clinical record lacked documentation of P5 having received and / or signed a consent for medical treatment form.


P6 was admitted to the CAH on 8/12/13, per P6's Admission Summary Sheet. P6's clinical record lacked documentation of P6 having receiving and / or signed a consent for medical treatment form.


P9 was admitted to the CAH on 7/9/13, per P9's Admission Summary Sheet. P9's clinical record lacked documentation of P9 having received and / or signed a consent for medical treatment form.


P20 was admitted to the CAH on 4/16/13, per P20's Admission Summary Sheet. P20's clinical record lacked documentation of P20 having received and / or signed a consent for medical treatment form.


On 4/17/14, at 11:50 a.m. the director of medical records confirmed each patient should have been given a consent for medical treatment form to sign. The medical director stated if a clinical record lacked the consent form documentation she would not be able to confirm consent had been given by each patient who received medical treatment at the CAH.


The CAH's Consent policy "Consent - General Consent" last revised 3/2013, stipulated
"Consent must be obtained in all situations prior to any procedure, except in situations which constitute an emergency." Section C of this policy further indicated the written and signed consent form became part of the patient's permanent clinical record.


18617

P23's emergency room clinical record did not include appropriate documentation to describe the patient's progress, response to interventions, and disposition at the time of discharge.


P23's clinical record revealed P23 presented to the emergency room (ER) on 4/3/14, at 4:31 a.m. with a chief complaint of "Hallucinations" and was diagnosed with "Meth toxicity." The provider plan indicated IV fluids and cardiac monitoring would be provided. P23's nurses notes dated 4/3/14, at 4:58 a.m. confirmed P23 was admitted to the ER due to hallucinations. No further documentation related to the observation of the patient's condition was made until 10:07 a.m. (5 hours and 9 minutes) when RN-D documented "WE [White Earth] crisis team called and will be sending a team here for pt." At 10:28 a.m. RN-D documented P23 left ambulatory through the ER door and the police department (PD) was notified. At 10:37 a.m. RN-D documented the PD had returned P23 back to the emergency room at which time P23 signed self out against medical advice (AMA). P23's ER record lacked identification of cognitive status, neurological status, or psychiatric status throughout the course of treatment while P23 was in the ER. P23's record also lacked identification of who P23 had left the hospital with and the provider section of the ER record identified as "Disposition" was documented as "None."


RN-D was interviewed on 4/16/14, at 2:30 p.m. and stated ER patients were supposed to be observed at least every hour and the observation was also to be documented hourly. RN-D confirmed P23's observations, assessments, response to interventions, neurological & psychiatric status and disposition at the time of discharge were not documented.


A policy related to documentation and assessment guidelines including documentation of disposition at the time of discharge was requested but not provided.


The chief executive officer was interviewed on 4/16/14, at 2:15 p.m. during which she confirmed that documentation related to the patients observations, assessments, response to interventions, neurological & psychiatric status and disposition at the time of discharge was not documented.

Based on document review and interview, the Critical Access Hospital (CAH) failed to ensure policies and procedures were developed which clearly delineated the procedure for peer review related to appropriateness of medical diagnosis and treatment when a potential "outlier" was identified. This practice had the potential to effect all patients treated in the CAH.


Findings include:


Review of the 2013, Peer Review documentation was conducted and revealed a physician, not employed at the facility, reviewed patient records and provided feedback as to the appropriateness of medical diagnosis and treatment.


A policy was requested related to the peer review process to determine how the CAH chose outliers for peer review but was not provided.


On 4/18/14, at 12:10 p.m. the chief executive officer (CEO) stated the CAH did not have a policy or procedure related to peer review. The CEO stated that if there was a patient death then that record would go out for peer review. The CEO also stated the medical records specialist chose the clinical records for Peer review but did not know the criteria for choosing potential outliers.


On 4/18/14, at 12:15 p.m. the medical records specialist stated she chose clinical records for peer review based on diagnoses and chose only inpatient records that had multiple diagnoses or co-morbidities. The medical records specialist stated that none of the emergency room records were included in the peer review process unless an inpatient was admitted from the ED and the ED record was reviewed along with the inpatient record.




32601

On 4/18/14, at 9:30 p.m. the CEO confirmed mid-level providers (certified nurse practitioners and physician assistants) should have sent a portion of their patient's clinical records to their assigned medical doctor (MD) for review of the care and management of their patients. The CEO stated this process was not being monitored to assure completion according to the CAH's policy. The CEO was unable to provide a list of charts each medical doctor had reviewed or evidence demonstrating follow up was completed when a concern was identified.

On 4/18/14, at 10:30 p.m. the CEO verified there was no evidence of documentation with regards to chart review discussions between the MD and mid-level's as those conversations were done informally.

The CAH's Medical Staff Chart Review policy dated 9/2013, revealed 25% of emergency room (ER) patient records should be forwarded by the mid-levels to a medical doctor for cosignatory.

Based on interview and document review, the Critical Access Hospital (CAH) failed to develop an abuse policy and procedure to include the immediate notification of the State agency. This had the potential to affect 1 of 1 current swing bed (SB1) resident and all future swing bed residents receiving services by the CAH.

FINDINGS MOVED TO CMS 2567 FOR THE SWING BED

Findings include:


The CAH's Vulnerable Adult Act Policy and Procedure revised 3/2013, had internal reporting procedures which directed staff to do the following: "...An internal investigation will be initiated within the first 24 hours with the involvement of the Director of Nursing, Social service designee, and Administrator. Within twenty-four (24) hours of notification of the incident, and if the incident is reportable, the OHFC (Office of Health Facility Complaints) will be contacted as well as the Common Entry Point designated by the county..."


The facility licensed social worker (LSW) was interviewed on 4/18/14, at 9:45 a.m. and stated she was responsible for implementing the CAH's Vulnerable Adult Act Policy and Procedure. The LSW confirmed she was not aware a vulnerable adult (VA) report was required to be made to the State Agency and Common Entry Point immediately after a VA incident occurred.

FINDINGS HAVE BEEN MOVED TO THE CMS 2567 FOR SWING BED.

Based on interview and document review. the Critical Access Hospital (CAH) failed to ensure a written investigation was completed within 5 working days of an allegation of abuse/neglect, and the incident was immediately reported to the State agency for 1 of 1 swing bed (SB)-3 resident's reviewed who had an allegation of abuse/neglect.


Findings include:


Review of the COMMON ENTRY POINT (CEP) INTAKE FORM dated 3/5/14, indicated the daughter of SB3 had reported concerns related to SB3's discharge location and stated SB3 was at risk for misappropriation of funds, neglect, drug and alcohol abuse and physical abuse. SB3's daughter stated it would not be a safe environment for SB3. Therefore, SB3's daughter indicated she was searching for alternative placement for SB3's own safety. There was no written evidence to suggest the state agency was immediately notified of the incident and no further written investigation was completed related to this incident.


On 4/18/14, at 10:10 a.m. the licensed social worker (LSW) stated she reported the incident to the common entry point (CEP) because she felt the facility had discharged SB3 to a situation that had the potential for physical abuse, neglect and financial exploitation. The LSW stated at the time of discharge SB3's grand daughter had impersonated the niece of SB3 and brought SB3 back to SB3's home although SB3 and the grand daughter knew that SB3 should not live there because the other daughter of SB3 had weeping shingles. The LSW stated she had attempted to call SB3 to make sure she was alright but SB3 had given the LSW the address and telephone number to her niece's house and not the home of SB3 therefore, the LSW was unable to call SB3 to verify if she was OK. The LSW confirmed she had not documented the investigation related to the aforementioned incident within 5 working days, and had not immediately reported the incident to the State Agency according to the facility policy.


The CAH's Vulnerable Adult Act Policy and Procedure revised 3/2013, had internal reporting procedures which directed staff to do the following: "...An internal investigation will be initiated within the first 24 hours with the involvement of the Director of Nursing, Social service designee, and Administrator. Within twenty-four (24) hours of notification of the incident, and if the incident is reportable, the OHFC (Office of Health Facility Complaints) will be contacted as well as the Common Entry Point designated by the county...3. An investigative report must follow the initial OHFC report within 5 days of the incident"